A. Takahagi

Postoperative pulmonary function and complications in living-donor lobectomy

BACKGROUND Successful living-donor lobar lung transplantation largely depends on the donors outcome. Because surgical skills and peri-operative management have evolved over time, this study evaluated the recent outcomes of donor lobectomies. METHODS Between 2008 and 2014, 48 consecutive living-donor lobar lung transplantations with 85 donor lobectomies were performed at Kyoto University. All donors were prospectively followed up regularly until 1 year after surgery. RESULTS Right and left lower lobectomies were performed in 49 and 36 donors, respectively. Pulmonary arterial branches were sacrificed at equal frequency in both lobectomies, whereas pulmonary arterioplasty was only performed in left lower lobectomy (n = 9). All donors were discharged after the lobectomies, and none died during follow-up. Post-operative complications occurred in 24 donors (28%) overall, without a significant difference between donor sides. Intraoperative complications were found in 2 donors. Early and late post-operative complications were noted in 17 and 6 donors, respectively. Pneumothorax, pleuritis, and pleural effusion were the most frequent. Post-operative pulmonary function sequentially recovered more than expected and was not significantly affected by the sacrifice of pulmonary arterial branches during lobectomy. By contrast, pulmonary function at 1 year after donor lobectomy in the donors who had peri-operative complications was significantly lower than that in the donors who did not, although even post-operative pulmonary function in the donors with peri-operative complications still recovered more than expected. CONCLUSIONS Living-donor lobectomies have been safely performed in recent decades with low morbidities and without mortality.

Association of Local Intrapulmonary Production of Antibodies Specific to Donor Major Histocompatibility Complex Class I With the Progression of Chronic Rejection of Lung Allografts

Background Antibody-mediated rejection may lead to chronic lung allograft dysfunction, but antibody-mediated rejection may develop in the absence of detectable donor-specific antibody (DSA) in recipient serum. This study investigated whether humoral immune responses develop not only systemically but locally within rejected lung allografts, resulting in local production of DSA. Methods Lewis rats received orthotopic left lung transplantation from Lewis (syngeneic control) or Brown-Norway (major histocompatibility complex-mismatched allogeneic) donor rats. Rats that underwent allogeneic lung transplantation were subsequently administered cyclosporine until day 14 (short immunosuppression) or day 35 (long immunosuppression). The lung grafts and spleens of recipient animals were tissue cultured for 4 days, and the titer of antibody against donor major histocompatibility complex molecules was assayed by flow cytometry. Explanted lung grafts were also evaluated pathologically. Results By day 98, DSA titers in supernatants of lung graft (P = 0.0074) and spleen (P = 0.0167) cultures, but not serum, from the short immunosuppression group were significantly higher than titers in syngeneic controls. Cultures and sera from the long immunosuppression group showed no production of DSA. Microscopically, the lung grafts from the short immunosuppression group showed severe bronchiole obliteration and parenchymal fibrosis, along with lymphoid aggregates containing T and B cells, accompanying plasma cells. These findings suggestive of local humoral immune response were not observed by days 28 and 63. Conclusions DSA can be locally produced in chronically rejected lung allografts, along with intragraft immunocompetent cells. Clinical testing of DSA in serum samples alone may underestimate lung allograft dysfunction.

Anterior mediastinal tissue volume is correlated with antiacetylcholine receptor antibody level in myasthenia gravis

Objectives: Extended thymectomy is a treatment option for myasthenia gravis (MG), but the surgical indications are controversial. Pathologic features of the thymus can be used to predict surgical outcomes, but there is no reliable method for evaluating these characteristics preoperatively. The purpose of this study was to determine whether anterior mediastinal tissue volume, as measured via 3‐dimensional computed tomography (3DCT) volumetry, correlates with serum anti‐acetylcholine receptor antibody (AChRAb) levels in patients undergoing thymectomy for myasthenia gravis. Therefore, we investigated the relationships among anterior mediastinal tissue volume determined by 3DCT volumetry and AChRAb levels. Methods: The subjects were 28 patients who underwent extended thymectomy and were enrolled retrospectively. We measured volume of the anterior mediastinum and calculated the volumes of more than −30 Hounsfield units (V−30) by using 3DCT volumetry and compared them with perioperative AChRAb levels. The significance of their volumes in MG was examined by comparison with 53 patients without MG. Results: V−30 values were related to age and were significantly greater in patients with MG than in patients without MG (P < .001). V−30 values were correlated positively with preoperative AChRAb levels (&rgr; = 0.505, P = .006) and inversely with the post/preoperative AChRAb ratio (&rgr; = −0.453, P = .018). The histologic nonadipose tissue ratio was correlated with the V−30/volume of the anterior mediastinum (&rgr; = 0.700, P < .001). Conclusions: This method for evaluation of the anterior mediastinal tissue volume and AChRAb production may be helpful in establishing a treatment plan for MG.

Lung autotransplantation technique for postpneumonectomy-like syndrome

From the Departments of Thoracic Surgery and Cardiovascular Surgery, Kyoto University Graduate School of Medicine, Kyoto, Japan. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication April 25, 2015; revisions received June 7, 2015; accepted for publication June 14, 2015; available ahead of print July 26, 2015. Address for reprints: Hiroshi Date, MD, Department of Thoracic Surgery, Kyoto University Graduate School of Medicine, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan (E-mail: hdate@kuhp.kyoto-u.ac.jp). J Thorac Cardiovasc Surg 2015;150:e45-7 0022-5223/

Protective Effect of a Hydrogen-Rich Preservation Solution During Cold Ischemia in Rat Lung Transplantation

36.00 Copyright 2015 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2015.06.048

Native upper lobe-sparing living-donor lobar lung transplantation maximizes respiratory function of the donor graft

・Anesthesia: pentobarbital 120mg/kg i.p. ・Ventilation setting: (O2 100%, Tidal volume (VT) 7ml/kg, RR 70/minutes, PEEP 2cmH2O) ・Preservation solution (perfadexR) flushed through the main pulmonary artery with 20 mL ・In the hydrogen group, hydrogen added to the preservation solution more than 1 ppm using hydrogen generation agent “水素水7.0 aquela”. ・Orthotopic left lung transplantation using cuff technic.

A case of multiple pleural cryptococcosis without pleural effusion.

BACKGROUND We have developed a novel method for native upper lobe-sparing living-donor lobar lung transplantation (LDLLT) to overcome a small-for-size graft in standard LDLLT with acceptable results. We hypothesized that grafts implanted with this procedure might work more efficiently than those in standard lobe transplantation. METHODS Bilateral LDLLT was performed in 31 patients with a functional graft matching of less than 60% at our institution between August 2008 and December 2015. Of these, 22 patients were available for evaluation of pulmonary function more than 1 year later: 15 undergoing standard LDLLT with less than 60% functional matching and 7 undergoing native upper lobe-sparing LDLLT. RESULTS Overall survival at 2 years was 87.5% in the lobe-sparing LDLLT patients and 79.0% in the standard LDLLT patients (p = 0.401). The median forced vital capacity size-matching levels were 50.7% ± 1.6% in the standard LDLLT and 45.2% ± 2.3% in the sparing LDLLT group (p = 0.074). The 1-year and 2-year post-operative volume ratios of inspiration to expiration were significantly different between the 2 groups, at 1.76 and 1.45 after standard LDLLT (p = 0.019) vs 2.41 and 2.23 after lobe-sparing LDLLT (p = 0.015). CONCLUSIONS The grafts in lobe-sparing LDLLT functioned more effectively than those in standard LDLLT. This advantage was associated with the improvement of pulmonary functions.

Pulmonary Function and Exercise Capacity in Patients With Flat Chests After Lung Transplantation

Pulmonary cryptococcosis is most likely to occur in immunocompromised patients. The radiological manifestations generally include pulmonary parenchymal lesions, namely, pulmonary nodules, cavitary lesions, and consolidation; thus, multiple pleural nodules are unusual presentation. Here, we report a woman who presented with multiple pleural cryptococcosis without pleural effusion. The patient had previously undergone surgery for stage II rectal cancer. In addition, she received 6 cycles of chemotherapy for follicular lymphoma. Computed tomography (CT) revealed multiple small nodules involving the pleura without pleural effusion, which suggested possible recurrence of rectal cancer or malignant lymphoma as pleural dissemination. Thoracoscopic examination was performed, and pleural cryptococcosis was diagnosed. Although pleural cryptococcosis without pleural effusion is extremely rare presentation, clinicians should consider it when an immunocompromised patient presents with multiple pleural nodules. Thoracoscopic exploration should be the best procedure for the definitive diagnosis of multiple pleural nodules.